Healthcare SIU
Deirdre Mathis
Kuna,ID
Summary
Motivated Fraud Analyst touting five years of expertise investigating suspicious activity for Healthcare insurance company. Knowledgeable administrative professional with expertise in medical records management, coding and data entry. Proven ability to review and document clinical data, ensuring accuracy and compliance. Well-versed in ICD-10, CPT and HCPCS coding systems.
Overview
6
6
9
9
Healthcare Insurance
10
10
years of professional experience
Work History
SIU Prepayment Analyst Lead
Blue Shield Of California
Rancho Cordova/ Remote, CA
Jan.2019 - Jun.2023
- Supervised high performing team of Seven, initiated training, and staff development initiatives, prepared monthly reporting of prepayment inventory/saving for sr
- Leadership team
- Coordinates team efforts to recover erroneous payments made because of claims processing error, misrepresentation billing FWA
- For FY 2018-2022 realized saving of $40+million
- Utilize/experience various programs: Facets (front and back end), Auth Accel, Word, Excel, Adobe, Outlook, DOFR, Health Care Fraud Shield, Tableau, Fep Direct, Blue2, Tableau Advanced Excel
- Handles escalated issues and most complex activities, including all areas of prepayment review, as well as other areas within department
- Conducted Routine Quality assurance review of work completed by other team members with high degree of accuracy in identifying errors, communicates audit findings to management and team member, also ensures all reviews meet enterprise policy, and are in line with state and federal laws, and align with AMA's CPT coding guidelines
- Implements process improvement and ensures processes are documented; creates and maintains documentation for workflow
- Support investigative staff in in all aspects of FWA investigation, including review and analysis of obtained data, medical records, public records, social media creating provider instructions and claims data mining correct coding and interviews entity review, law enforcement referral, and use of proprietary data and claim systems for review of facility, professional and pharmacy claims
- Responsible for identifying specific healthcare investigations that may impact more than one company health plan, line of business and/or state
- Partnered with other SIU investigative staff on discovering new potential cases, risks, and triage of potential cases
- Monitored employee tasks to gauge business functions and inefficiencies
- Resolved or escalated problem tickets to resolve user issues.
- Defined and documented scope of projects for distribution to team.
SIU Advance Prepayment Processor
Blue Shield of California
Nov.2016 - Dec.2019
- Responsible for multiple flagged claims, appeals, and clinical documentation review doe subjects under investigation across all lines of business
- Processed 150+ claims/ correspondence cases daily
- Performs other duties/assignments within prepayment, as well as other areas within department
- Specialized in complex areas including mental/behavioral health, DME, Home health, facility and foreign providers, independently review documentation and makes decisions based on review of source documentation
- Tasked with review and analysis of internal processes including root-cause analysis and identifying opportunities for improvement in efficiency and compliance
- Assisted in investigation interviews of providers and members
- Developed and published desk level procedures, policy and procedures, and manuals that encompassed all process of prepayment review team
Appeals and Grievance Clinical Coordinator
Blue Shield of California
Jan.2015 - Nov.2016
- Receive 20+ appeals case from members pertaining to claim and authorization denials
- Research and analyze each case with regards to member benefits and claim payment/denial details
- Work with external providers (doctors, IPA, Brokers, Pharmacy's) to get medical records or set up peer to peers
- Write letters to members and providers utilizing blue shields letter writing standards and protocols
- Coordinated, monitored, assigned, and documented patient and clinical care activities
- Assessed clinical policies and procedures for compliance with changing regulations.
CalPERS Specialized Customer Representative
Blue Shield of California
Oct.2013 - Dec.2014
- Eligibility and Benefits / Claims specialist for University of California, CalPERS, and special and custom accounts
- Skilled in Shield Concierge, experienced with Case Trakker Dynamo, MCPS, Appeals and Grievances
- Effective communication with external business partners such as IPA/Medical Groups, PPO/HMO Physicians as well as Hospitals, Ancillary Providers and Blue Shield members
- Interim Lead, RTA Assist line, Chair siding observation, resolving escalations, Help and Train Reps
- Offered advice and assistance to customers, paying attention to special needs or wants
- Clarified customer issues and determined root cause of problems to resolve product or service complaints
- Helped large volume of customers every day with positive attitude and focus on customer satisfaction.
- Collected customer information and analyzed customer needs to recommend potential products or services
- Responded to customer calls and emails to answer questions about products and services
Education
Certificate -
American Academy of Professional Coders (AAPC)
Online11.2023
High School Diploma -
Ponderosa High School
Shingle Springs, CA2004
Skills
- Activity Monitoring
- Fraud Investigations
- Data Analysis
- Fraud Prevention and Detection
- Insurance Industry Experience
- Microsoft Office
- Case Research
- Insurance Terminology
- Work Organizing and Prioritizing
- Policy and Procedure Explanations
- Regulatory Compliance Adherence
- Insurance Claims
- Electronic Claims Processing
- Advanced Excel Spreadsheet Functions
- Benefits Guidelines
- Medical Terminology
- Interview Skills
- ICD-10 Coding
- Leadership and supervision/ Team monitoring
Timeline
SIU Prepayment Analyst Lead
Blue Shield Of California
Jan.2019 - Jun.2023
SIU Advance Prepayment Processor
Blue Shield of California
Nov.2016 - Dec.2019
Appeals and Grievance Clinical Coordinator
Blue Shield of California
Jan.2015 - Nov.2016
CalPERS Specialized Customer Representative
Blue Shield of California
Oct.2013 - Dec.2014
Certificate -
American Academy of Professional Coders (AAPC)
High School Diploma -
Ponderosa High School
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